Knowledge and attitudes of midwives regarding postpartum depression in a developing country

¹Laboratory of Clinical Neurosciences and Mental Health, Hassan II University, Casablanca, Morocco, ²Adult Psychiatric Department in Hospital Center Ibn Rochd, Casablanca, Morocco

^&Corresponding author
Raoui Aicha, Laboratory of Clinical Neurosciences and Mental Health, Hassan II University, Casablanca, Morocco

Introduction    

Postpartum depression (PPD) is an affective disorder that throws new mothers into deep gloominess, typically between four and eight weeks after giving birth, though it can occur at any point within the first year. It's a matter of great public health importance that demands attention, as early detection and adequate treatment are crucial to prevent disastrous consequences [1]. Postpartum is also a period where women are incredibly vulnerable. On top of changes in the body, hormone changes, and peer pressure, overwhelm is sure to occur. A mother's mental health is, however, paramount in obtaining a healthy parent-child relationship as well as healthy family functioning. Most women do not have the means to express their discomfort, and most often, the symptomatology of postpartum depression is missed.

The majority of new mothers´ experience what's commonly called the baby blues, a transient disturbance of mood that usually manifests on the third day after giving birth. It is marked by excessive tearfulness, heightened sensitivity, but disappears quickly, especially with the presence of loved ones [2]. This must not be confused with postpartum depression, which affects approximately one in seven women, lasts longer, and significantly impairs a mother's functioning normally [3]. Postpartum depression (PPD) is usually undiagnosed, and its underdiagnosis can have serious consequences, ranging from mood disorders to the worst acts of infanticide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) mentions PPD as a major depressive episode with childbirth, within four weeks of delivery [3]. Midwives are at the forefront of prevention, awareness, and screening for PPD. The present study is in line with this perspective and aims to establish the knowledge and equipment of midwives in handling this significant public health issue.

Methods     

Study design: this cross-sectional and descriptive research was conducted with Casablanca midwives. The intention was to screen their attitudes as well as awareness regarding PPD to improve management.

Setting: the investigation was targeted toward midwives from some of Casablanca's hospitals, in addition to midwives at El Jadida, 96 kilometers south of Casablanca city. The three-month study period ran from January to March 2024.

Participants: the target population consisted of midwives working in the selected hospitals. Participation was voluntary and non-remunerated. All midwives were informed about the study objectives, procedures, and the confidentiality of their responses before providing consent.

Variables: the primary variables measured were midwives´ knowledge, attitudes, and level of awareness regarding PPD. Additional variables included years of experience, age, professional setting, and personal history of psychological consultation or symptoms of PPD.

Data sources/measurement: Google Forms was used to build a survey with 34 open-ended and closed-ended questions. It was split into three pieces and given to midwives in two ways (mostly in-person, with some submissions made online) (Annex 1). General information: initial five inquiries. Attitudes: nine inquiries. Knowledge: twenty questions derived from comparable studies in Australia [4] and France [5] that were translated and transferred. Scoring using a system that allotted 1 mark for each right answer out of a total of 20 simple and multiple-choice questions. A mean score was determined (for example, 13.43/20 (67.2%)).

Bias: to minimize response bias, anonymity was ensured, and participants were encouraged to answer honestly. The use of validated questions from previous studies helped enhance reliability.

Study size: all available and consenting midwives working in the selected facilities during the study period were invited to participate. No formal sample size calculation was conducted; the sample reflects the total number of accessible respondents during the timeframe.

Quantitative variables: quantitative variables, such as knowledge scores, were analyzed as continuous data (mean score out of 20), and also categorized into low, moderate, or high levels.

Statistical methods: descriptive statistics (percentages, means) were calculated. The data collected were analysed using Microsoft Excel 2019.

Ethical considerations: this study did not involve patients or sensitive personal health information. It was conducted exclusively among professional midwives in their workplace. According to institutional policies, no ethical approval was required, as the participants were healthcare professionals, and no medical intervention was performed. All participants were informed about the objectives of the study and consented voluntarily to take part in the survey. As no formal approval number was issued, no ethical clearance number is available.

Results     

Participants: the sample consisted of 71 midwives, almost half of whom (46%) were aged between 30 and 40 years. Nearly all participants (97%) were employed in the public sector, and the majority (60.6%) had between 5 and 20 years of professional experience. Of these, 44 had one or more children, and 50% reported having experienced symptoms of postpartum depression (PPD). In addition, 25% of the midwives had received professional psychological support at some point in their lives (Table 1).

Descriptive data: a total of 55% of participants reported never having received formal education or training on PPD. Only 18% could correctly identify all the symptoms of PPD, and 14% mistakenly believed that the condition resolves on its own without intervention. Barriers to care were clearly identified by respondents: 51% cited a lack of knowledge among healthcare providers, and 36% pointed to insufficient social support as a contributing factor to underdiagnosis or lack of management.

Outcome data: regarding risk factor awareness, 70% recognized prematurity, 94% identified complications during delivery, and 92% cited neonatal morbidity as a risk factor for PPD. Although 96% of midwives agreed that screening for PPD is essential, only 10% were able to correctly state the typical onset period of symptoms. Alarmingly, none of the participants reported using the Edinburgh Postnatal Depression Scale (EPDS) in their practice, and 33% believed that no screening tools existed at all.

Main results: several misconceptions about treatment were revealed. While 93% acknowledged the role of psychiatric medication, 23% believed that antidepressants cause addiction, and 28% thought they produce immediate relief. The overall average knowledge score was 10.32 out of 20. Based on score categorization, only 6% of participants achieved a high score (above 75%), 39% scored within the moderate range (50-75%), and 55% scored below 50%.

Discussion     

The results refer to a significant lack in the training of midwives in postpartum depression. While they were experienced (60.6% had 5 to 20 years of experience) many lacked basic knowledge about PPD. This agrees with the conclusions of international studies [6] and refers to the need for special training programs. Midwives' professional perspectives were also impacted by their personal experiences with PPD. Of the childbearing midwives, 25% had sought psychological consultation, and half had experienced symptoms of PPD. Studies from Australia [4] and Egypt [7] found similar patterns, indicating that midwives' knowledge and empathy may be impacted by personal experience with mental health issues. However, while lived experience can raise awareness, it is no replacement for formal training based on clinical evidence. Barriers to care also complicate the issue. Limited healthcare provider awareness (51%) and limited social support (36%) were reported as important barriers. These results illustrate the systemic nature of the difficulties in treating maternal mental health and are consistent with research conducted in London [8] and Switzerland [9]. To solve these challenges, a multilateral approach comprising improved screening practices, increased integration of mental health services, and increased public awareness would be required.

The absence of standardized PPD screening instruments is particularly concerning. None of the midwives could accurately identify the current instruments, despite the fact that 96% of them acknowledged the need for screening. This stands in contrast to findings from France [5], where a higher percentage of midwives knew and utilized screening tools on a regular basis, such as the Edinburgh Postnatal Depression Scale (EPDS). Systematic screening is the cornerstone of early detection and intervention, but is hindered from being implemented by a lack of training and institutional guidelines for most midwives. There are also misbeliefs about psychiatric treatment. Although 93% knew the role of medication, many had out-of-date beliefs, such as antidepressants being addictive (23%) or having an immediate effect (28%). These misbeliefs are comparable with those found in France [10] and Uganda [6], demonstrating that a lack of psychopharmacology education is a global issue. Such misbeliefs may partially explain why midwives are reluctant to refer patients for adequate treatment, once more postponing much-needed care.

Maybe the most alarming suggestion from this research is the extreme degree of underestimation of suicide risk in PPD in women. Only 11% of midwives accurately predicted that 15% of women with PPD will attempt to take their own lives. Compared to 35% of the risk being underestimated at just 1%. This is particularly worrying as suicide is one of the leading causes of maternal death during the postpartum period. Such underratings have been found to exist in research in Australia [4], indicating a lack of awareness of epidemics. In addition, a major role falls to stigma. The majority of women who are considering suicide won't seek help because they're afraid of criticism, being "unfit mothers," or of losing custody of their child. Midwives, as the primary health workers of expectant mothers, must be properly trained to recognize signs and be sensitive. Overall, the total average score of 10.32/20 shows huge heterogeneity in midwives' knowledge about PPD. Despite the general awareness of the need to screen, knowledge gaps regarding available tools, treatment, and suicide risk are still main issues. Filling these holes with standardized education and continued training isn't just an issue of covering bad maternal mental healthcare it could also be a matter of life or death by ensuring suicidal mothers receive the care they so desperately require.

Limitations: this study has some limitations. First, responses were based on self-reported data, which may be subject to social desirability bias, particularly concerning attitudes or practices related to mental health. Second, recall bias may have influenced responses on past experiences with PPD. Finally, since participation was voluntary, there is a risk of selection bias, as those more interested or aware of the topic may have been more likely to respond.

Generalizability: the generalizability of the findings is limited to midwives working in hospital-based settings within urban areas of Morocco, particularly Casablanca and El Jadida. These results may not fully reflect the knowledge and attitudes of midwives practicing in rural regions, in private clinics, or in community-based settings, where access to mental health resources and professional training may differ significantly. Nevertheless, the study offers valuable insights into the current gaps in awareness and practice among frontline maternal care providers in urban healthcare environments.

Conclusion     

To address maternal mental health in Morocco, it is crucial to consider midwives' perspectives and knowledge about postpartum depression. These findings emphasize the significance of collaboration in enhancing care for this frequently overlooked condition. Implementing training programs, increasing awareness, and using systematic screening tools such as the EPDS are essential for early detection and intervention. Educating midwives to high levels of knowledge will enable them to recognize distressed women more readily and refer them to relevant care. At the same time, destigmatization and sensitization campaigns among the public and midwives must be carried out. Erasure of the glamour surrounding PPD and opening up about it will make more women want to be open to seeking assistance. For ensuring a comprehensive and integrated approach to PPD treatment, there must be some coordination among midwives, mental health workers, and local NGOs. Closing such gaps will raise PPD screening, treatment, and care in a big way for Moroccan women. It will improve the mental health of the community and the family, as well as the individual. Follow-up studies would aim to quantify the effects of midwifery education on maternal mental health outcomes and treatment efficacy training. The health of mothers and infants would be improved if postpartum depression were addressed at the national policy level.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All authors contributed equally to the study design, data collection, data analysis, as well as manuscript writing and revision. They also participated in the interpretation of the results and the final validation of the study. All authors read and approved the final version of the manuscript.

Table     

Table 1: description of sample characteristics

Annex     

Annex 1: postpartum depression questionnaire (PDF - 129KB)

References